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SAN.IOAQUIN COUNT\' ENVIRONM1IEN'rAt. HEAL IIt DFPARTNIENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ PACILRY ID I SERVICE REQUEST p <br /> 1 K�Si�uRp• �Apo2y�i — <br /> it <br /> OWNER I OPERATOR CHECK d BILLING ADOPESS <br /> �I Glut)IXIAD14 <br /> FACILITY NAME D O S A e l e yil c qrH a 1 <br /> SITE ADDRESS 1�0 2$OS r\IAL\Lfcr d'zeRr) I�Acy q$3o4 <br /> Sirtll Numbe I n51.1 Nom <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> $IrNI NUTMI tree Name <br /> CITY STATE ZIP <br /> PHONE 11 E., APN a LAND USE APPLICATION e <br /> l ) <br /> PHoNE*2 En SOS DISTRICT LOCATION CODE <br /> 1 1 -- <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR CHECK It BILLING ADDRESS❑ <br /> � N �J.M)tVFgp E.' <br /> BUSINESS NAME (� RnlI^ ` Crl,�AI cl-K, PNONOa 31 C(cL <br /> HOME Or MAILING ADDRESS EF •[ 'C' 1. r\ FAX# 6 <br /> z ("s O ( I <br /> CITY STATE zip C}530 <br /> BIL LINC ACKN0RLE0(;EMENT: 1, the undcnigned property or business oener, operator or autbnrired agent or same. <br /> ad.no\\Iedgc that .dl .ile and or project specilic h\\1NI AkIl\I v Iii \I ul D1 I,AKI\II Ni hourl\ chargc�asx,ciated with this project <br /> III,uati\it\ l%ill be billed n,me or nn business ae Identilied on till,ti,rnt. <br /> ako cenrt\ that I base prepared this application and that the\sort to be perl"ormed sill be done in accordance s ilh all S:\\b+u;t 1\ <br /> Ct n \1\ Onhinam a Codes.Sianskird+,ti I,\I I d-r nt R:U lass. <br /> APPLICANT'S SICNATURF.: Dillt: <br /> PNnI•INI\ Bill\I110NNIII13 OPLRst( : \\7 %(;IR OIIURAttHONVrn Al.s Ni0 <br /> k I;;c nlmnhr lllr mlr!'urrl.prnoj(jeurkdri.aridniHsigni.+required Itile <br /> ITHORIZATION' TO It F.LEASE INFORMATION: N hen applicable. h the usner or operator of the proper[+ located at the <br /> abo\e site address, hcreM authorize file release of ani and all results, geotechnical data and or environmental site a+xssmenl <br /> information to the S\\ I\CIA -,I) I \\1NI IN\u%I\I Ib At Ill DLPARI\R\1 as,(N+n as it is asailahle al`12 111-`ane[title it is <br /> pro%ided to me or m\ representati\c. Y <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: All <br /> ^ ,` (t'�' �� C,�Ic.�/\ �Y o <br /> (VL11'n�r/r16 VV �011',t`�/L//l(r'/ SA IV <br /> JO may+ <br /> hEATH OfPgi�COURTMt/CSNTy <br /> ACCEPTEOBY: EMPLOYEE e: DATE: <br /> ASSIGNED TO: K- . /`h (QS EMPLOYEE O: DATE: <br /> Date Service Compleleld (IT already completed): SERVICECODE' W P I E: <br /> Fee Amount: _ Amount /S Payment Date 717 •j..D <br /> Payment Type lig Invoice A Check 1t Received By: <br /> EHD 48-02,025 SR FORM(Goicen Roo, <br /> REVISED 11/172009 <br />